Information reviewed

Ms D was unable to provide a response to my investigation as she
no longer resides in New Zealand and could not be contacted.

Information gathered during
investigation

This is a report about a man who suffered a pulmonary embolism
secondary to a deep vein thrombosis (DVT) after waiting more than
four hours at an Emergency Department for treatment. It is a tragic
story that highlights the risks associated with the increasingly
common phenomenon of overcrowding in Emergency Departments
throughout New Zealand. When departments are crowded, patients wait
a long time for triage and medical assessment, and nursing
resources are more thinly spread. Patient care may be jeopardised.
This report highlights the need for Emergency Departments and
District Health Boards to recognise the problem and respond
appropriately.

Overview

On 6 June 2001 Mr A was referred by his general practitioner, Dr
C, to the Emergency Department (ED) of the public hospital with a
DVT. Mr A arrived at the hospital at 5.20pm. The Emergency
Department was exceptionally busy and Mr A suffered a cardiac
arrest at about 9.25pm, before a doctor could assess him. He
initially responded to resuscitation attempts but suffered a second
cardiac arrest at about 9.38pm and was unable to be resuscitated.
Mr A died at 9.51pm. The cause of his death was a pulmonary
embolism secondary to a DVT.

Mr A's death raised concerns among nursing and medical staff
about the standard of care in ED, which were brought to the
attention of the hospital's management. As a result the hospital
initiated an internal sentinel event investigation. It provided me
with a copy of the report from this investigation. I will refer to
the findings and outcomes of that investigation in this report,
where appropriate, as the Sentinel Event Report.

Preceding events at the hospital's ED

On 4 June 2001 all registered nurses in the ED, concerned about
the number of patients and staff shortages, completed a
patient/incident form. The form was not addressed and it is unclear
who received it, or what action was taken as a result. The form
stated:

"Volume of [patients] too big for
Emergency Department & unable to move [patients] on due to lack
of beds in wards. Unsafe staffing for number of patients.

...

4 beds in corridor all full 6
[patients] in [observation] still having ambulances to come in
nowhere to put [patients]."

On the afternoon of 6 June 2001 the Triage Nurse, Ms D, filled
out a staff accident/incident notification sheet in which she
stated:

"Concerned that no matter how hard I
worked on this duty, the time between arrival and triage was up to
and at times longer than 1 hour. This didn't improve even with S/N.
[ ... ] helping for a short time by triaging in consult room. A
number of patients left without being seen."

Mr A's referral to the hospital

At the time of these events Mr A was 64 years old. His general
practitioner was Dr C. Dr C had been treating Mr A for hypertension
with medication, atenolol and Inhibace. Towards the end of May 2001
Mr A developed a cough. Dr C stopped the Inhibace because it could
have been the cause of the cough. Initially Mr A's cough improved
but it was only about 10% better.

At 12 midday on 6 June 2001 Mr A consulted Dr C with a number of
medical problems, including his cough. Dr C stated:

"He [Mr A] told me that the cough
had increased [from the May appointment]. He had gout in his right
big toe last week, which had settled after some self initiated
Colchicine and Voltaren, but his right calf had been swollen for
the last five days. He related how he had begun to get
significantly breathless with relatively simple exertion two weeks
ago, not so much on the flat, but any incline would do it."

On examination Dr C noted that Mr A's right calf muscle was
tense, swollen and painful. Mr A's blood pressure was 170/100. Dr C
suspected that Mr A had a DVT and recommended that he attend the
public hospital's ED for a Doppler scan and assessment. Mr A was
reluctant to attend the ED because he had previously waited a long
time before seeing a doctor. He agreed to have a Doppler scan
privately at a radiology clinic that afternoon.

Mr A returned to work at 3.00pm and at 4.15pm he attended the
radiology clinic for the scan. Dr C accompanied Mr A and sat with
him while the scan was performed. The scan confirmed the presence
of a DVT extending from the popliteal vein (the vein running behind
his right knee). Dr C explained the results of the scan to Mr A and
stressed the importance of immediate admission to hospital.

Dr C left Mr A in the sonography room to have a chest x-ray, and
discussed the scan findings with Dr I, a radiologist. While Mr A
was having his chest x-ray, Dr C telephoned the medical admitting
officer at the hospital to discuss Dr I's findings and Mr A's need
for treatment. Dr C recalled:

"I told [Dr B] that we had diagnosed
the DVT by scan and also related in detail the history of the
previous events relating to the increased hypertension, the
Inhibace and my concern that the breathlessness on exertion may
have been an exposed congestive [cardiac] failure. I told him about
the history of the swelling of the leg and gout and what
medications he had taken. I wrote a short hand-written note
summarising the pertinent points of the history and returned next
door giving this to the radiologist so he could attach a radiology
report to go with [Mr A] to the hospital. [Mr A] at that time was
having a chest x-ray so I didn't see him, but my understanding was
that he was going straight to the hospital from [the radiology
clinic]."

Dr C believed that he conveyed the seriousness of the immediate
clinical situation, as well as Mr A's other medical problems
(hypertension and recent gout).

After talking with the admitting medical officer he wrote a
quick referral letter, "very much [as] a secondary part of the
communication with the house surgeon (the personal communication
being the all-important part)". Dr C gave the admitting note to Dr
I and asked him to attach his request to the note and send it with
Mr A to the hospital as soon as the chest x-ray was completed.

Dr C expected that when Mr A arrived at the hospital the ED
staff would notify the medical admitting doctor and he would be
seen "more or less straight away". In Dr C's view he had identified
a serious medical problem needing urgent attention, conveyed the
urgency to the relevant inpatient team who would deliver necessary
treatment, and sent the patient to the hospital. However, "the
systems involved in the GP/hospital interaction and
patient/hospital interaction failed to place the patient under the
care of the inpatient team in the necessary timely manner".

Dr B was the admitting house surgeon for the medical inpatient
team at the hospital, and took Dr C's call. Dr B accepted Mr A for
admission because of his DVT but considered the referral was
non-urgent. Dr B said that he did not gain the impression from Dr
C's call that Mr A was unwell and considered that there was no
suggestion of pulmonary embolism. His general impression was that
"[Mr A] had an uncomplicated DVT, that he was well with this, and
that he would present to the Emergency Department in the usual way
for further evaluation upon his arrival".

Dr B telephoned the ED reception staff to inform them of Mr A's
personal details and diagnosis. He did not discuss Mr A with the
medical team or senior clinician or any ED doctors or nursing
staff, as it was not "routine practice ... unless some urgency is
conferred by the referring practitioner".

Supervision of junior doctors

Dr H, Clinical Director of Emergency Services, was not informed
that Mr A had been referred for admission.

Dr H noted that Dr B was a member of the inpatient medical team
and therefore she had:

"no ability to train, influence or
manage how and what [Dr B] did from a medical perspective. I have
never been invited to provide an overview of the role and function
of the ED in managing acute patient care during the sessions for
junior doctor introduction to the hospital."

Dr H informed me that, although she saw her Clinical Director
role as much broader, it was limited to managing the care of
patients who either self-referred to ED or who arrived by
ambulance. Mr A had been referred by his GP and was therefore not
under her care.

General practitioner referrals account for 40% of all patients
attending the hospital ED. Dr H advised me that, in her opinion,
first year junior medical doctors such as Dr B have insufficient
experience in managing GP referrals of acutely ill patients over
the telephone. Dr H stated:

"It is inappropriate for very young
doctors to be assessing acutely ill or injured patients alone or
with very little supervision. This is as much the case for face to
face presentations as with over-the-telephone referrals. Young
doctors do not know what they do not know."

Dr H advised me that such referrals should be made to a senior
ED doctor:

"It is no longer a reasonable
option, in my opinion, for definitive acute care to be divided
prior to the ED. It is inappropriate, risky and accountabilities
uncertain to continue the use of both inpatient acute call teams
and ED teams for the management of patients attending ED. This
division allows for gaps in care and it is ultimately the patient
who suffers. It is also significantly frustrating, for me to be
held accountable for a system of care that was not under my
influence. It is my opinion that GPs should be referring their
patients directly to the ED Senior Medical Officers rather than to
inpatient on-call teams. The exchange of important diagnostic and
therapeutic information is essential at such times."

ED attendance in early June 2001

Dr H advised me that June 2001 was particularly busy in ED for a
number of reasons. Suddenly, the numbers of elderly very ill acute
patients with multiple medical problems increased attendance rates
in ED by more than 25%. The severity of patients' illnesses meant
that each patient spent longer in ED, requiring longer nursing and
medical assessment. Inpatient numbers increased to at least 40
acutely ill patient admissions a day and each day began with 10
more patients than available beds. Patients were discharged sooner
than desirable to make room for new patients arriving. ED staff had
only 19 beds and were unable to find inpatient beds for patients
needing admission; a number of senior nursing staff left; and the
ED was unable to find junior doctors.

The Emergency Department Policy in relation to GP referrals,
developed by Dr H, dated December 2000, stated as follows:

"Analysis of Emergency
Department Operations - [the public hospital]

Emergency Department
Operations

The analysis of emergency department
operations is presented in relation with the following
processes:

summary of emergency room processes;

intake process;

medical evaluation process;

consultation and investigation process;

referral process.

Summary of
processes

The summary presented covers all of
the phases that may be involved in responding to the patient's
needs, from the time the patient arrives at the emergency room to
the time he or she leaves it.

Process on arrival in
emergency room: intake

The intake process constitutes the
patient's first contact with the emergency department. It is aimed
at collecting basic information on the patient, briefly
ascertaining the reason for the attendance, and registering the
patient, by activating his file or creating a new patient file.

The patient's first contact with the
emergency department should be with the triage nurse. Triage must
be done quickly and in accordance with the emergency department's
established protocols. The purpose of triage is to assign a
severity code for examined cases and determine the mode by which
the patient is to be seen (stretcher or ambulatory).

Medical evaluation
processes

This process involves the ED medical
staff (or, in the case of GP-referred patients, the on-call
inpatient clinical staff) and is aimed at arriving at a diagnosis
or medical opinion.

Evaluation-treatment

The maximum period for
evaluation-treatment by the emergency medical team/inpatient
on-call team, should be three hours. By the end of three hours, a
decision should have been made regarding further action with
respect to the patient's disposition: release, admission,
observation, consultation.

Consultation and
investigation process

It is essential to have a clear
policy regarding emergency consultations. It is recommended that
the period between the request for consultation and the
decision-making on the part of the inpatient team be two hours
(maximum of four hours if other tests prove necessary). By the end
of this period, the inpatient team should have made one of the
following decisions:

admission;

release or consultation needed in another specialty.

Referral
process

This process is aimed at healthy
management of stretcher use in the emergency department and
referral of clients to the proper resources on the basis of their
needs."

Dr H advised me that there is a lack of clarity and direction in
ED procedure and that the current system paralyses the ED team's
ability to work together. In her opinion the nursing staff feel
stymied and uncertain about what to do; on one hand nursing
management recommend one way of dealing with a patient, and on the
other hand senior clinicians and medical staff tell them to do
things another way. As the Director of the Emergency Department she
has tried to implement changes but has encountered a lot of
resistance, particularly from senior clinicians who do not seem to
want to become involved with GP referrals. In her view senior
clinicians should be consulted about the best course of action when
a GP refers a patient to hospital.

ED attendance on 6 June 2001

ED records indicate that on the evening of 6 June 2001 14 people
came to the reception desk between 5.00pm and 6.00pm; eight between
6.00pm and 7.00pm; seven between 7.00pm and 8.00pm; five between
8.00pm and 9.00pm; and seven between 9.00pm and 10.00pm. Fifty
percent of the attendees were GP referrals. Everyone needed medical
assessment and investigation before any decision could be made on
his or her admission. The number of people exceeded the number of
available beds or trolleys, leading to a backlog and delays in
meeting triage targets. The hospital advised me that "one triage
nurse is expected to assess a maximum of eight clients per hour".
The Sentinel Event Report notes:

"Given the numbers presenting during
the hours listed, she [the triage nurse] was not able to assess new
patients within the expected time frames. However there does not
seem to have been any attempt made to get additional assistance to
assess patients in a timely manner. It is fair to say that all
staff in the ED were working to their maximum capacity throughout
the shift, however the Operations Manager Clinical Units was not
informed of the prolonged waits for triage and medical
assessment."

The ED nurse co-ordinator on duty was Ms E. She described her
role as co-ordinator as very mobile, liaising with many people
within ED and outside in the wards and other departments in the
hospital. She attempted to move patients into beds for assessment
in ED or transfer them to the ward for admission. She dealt with
other personnel such as radiology, laboratory, after-hours support
staff, transport, orderlies and ward staff, as well as patients and
their families. Ms E also dealt with cases brought in by ambulance.
Ambulance cases impact heavily on bed availability because the
patient must be taken off the ambulance stretcher in the shortest
possible time. Inpatient admitting team doctors assess their
patients in ED before deciding whether to admit them.

Ms E advised me that the evening of 6 June had been
"extraordinary" because of the number of patients attending and the
increased severity of their illnesses. All medical teams were
working in ED and all teams had the wait for beds. The paediatric
team had priority on beds for sick children. This prioritisation
also limited the beds available for adults. Ms E stated that when
ED is busy "doctors tend to rifle the incoming notes" to access the
notes of their patients. This can cause notes to be out of order or
misplaced. Any free beds that become available are "hijacked by
doctors bringing in their own patients without discussion with the
co-ordinator". Ms E stated that both occurred between 4.00pm and
5.00pm and, although it did not "impact directly on [Mr A]", it
caused bed delays for everyone especially as all the beds were
occupied at the beginning of the shift. Ms E further stated:

"[Ms F, Operations Manager Clinical
Units] and I were in constant contact throughout the night. I do
not recall stating specifically to her that the Department was not
meeting triage times. I would not have thought to because,
historically, and even on quieter nights, we do not meet triage
times. Triage times become triage priorities."

Ms F advised me that when she arrived on duty Ms E told her ED
was busy and had seven patients in the observation unit, two of
whom were orthopaedic patients. When Ms E told her that two
patients were ready to go to the ward she went to the ward to check
whether beds would be available. She advised Ms E that the ward
staff were readying some patients for discharge. Within a few
minutes Ms F received a telephone call from a doctor advising her
that the ED was busy with seven patients in the observation unit
and that more staff were needed. This was soon after she received
the handover report at about 1.50pm. She told the doctor that she
had arranged for patients to be transferred to the ward and that
she would continue to monitor ED staffing throughout the shift. The
longest wait between a request for a bed and its provision was 20
minutes. Although she was aware the ED was busy, she was not
"requested to escort patients up to the ward or aware that patients
were not being triaged within established guidelines".

Mr A's care at the hospital

On 6 June 2001 Mr A drove himself from the radiology clinic to
the hospital, registering at ED reception at 5.20pm. The only
triage nurse on duty was Ms D. At 6.30pm Ms D assessed Mr A. She
recorded the following:

"R [right] (DVT) according to scan
results (in notes). Swelling started approx five days ago. Pain
three days ago. Some pain present at the moment in R (leg)."

Ms D took Mr A's observations and recorded: temperature 36.9,
blood pressure 175/103, pulse 64bpm, good colour, no apparent
shortness of breath and "talking in full sentences". Ms D
categorised Mr A as triage code 3, which means he should have been
seen by a doctor in 30 minutes. The Sentinel Event Report notes
that it appears Ms D may not have looked at the scan report "which
had the definitive diagnosis, and extent of the thrombus clearly
stated". The Report further states:

"The GP's cover note was cursory,
and gave no indication of the severity of the problem, though it
was written after the scan had taken place. However it would be
expected that the Triage Nurse would review all written information
available to her as this could influence clinical decisions."

Ms E received and read the notes between 7.15pm and 7.45pm. She
did not recall viewing the scan report at that time but remembered
reading the scan report later with Dr J. In her opinion the notes
and scan report were assessed accurately and adequately. She was
unable to bring Mr A in for assessment, observation or treatment
because there were no empty beds in ED.

Mrs G, Nurse Manager, advised me:

"I am of the opinion, that on the
evening of 06 June 2001, due to the numbers and acuity of patients
already in the waiting room and department and the 34 new patient
presentations to the ED between 1700 and 2100 hours as indicated in
the sentinel event report (Emergency Department Presentations 6
June 2001) [Ms D] was faced with a situation that was beyond safe
management by any nurse. She appropriately indicated that she was
unable to cope with the volume of patients arriving in the ED but,
due to the numbers of patients within the department, was only able
to be assisted for a short time by another ED staff nurse. In my
opinion, by the time [Ms D] was able to triage [Mr A], her workload
was such that she was not able to spend as much time triaging as is
optimal. This I believe is where the letter from [Dr C] can be
brought into question. While [Dr C] had included the doppler scan
report with his letter, [Ms D] had time to focus on his brief
letter only. She made her triage decision on the observations she
made of [Mr A], all of which were stable and not indicating any
reason for concern. She also read [Dr C's] note which stated that
[Mr A] had a 'Right leg DVT'. It did not indicate the concern that
[Dr C] had regarding this patient. It does indicate that the
doppler scan report was available, however [Ms D] may not have read
this due to the volume of work she was faced with. In light of the
brief information in [Dr C's] letter and the current practice of
treating many patients with diagnosed DVT as outpatients, it was
not unreasonable for [Ms D] to have coded [Mr A] as needing medical
care within 30 minutes."

The Sentinel Event Report states:

"After triage, [Mr A's] notes were
placed in the Triage/patient waiting box on the clinical
workstation, ready for the doctor's use. These are filed according
to triage category to ensure timely assessment of each category.
The ED Nurse Co-ordinator read the triage notes, and despite
reading the scan report, took no action, as there were no beds
available for the patient to be seen by the medical staff at that
time. There is no evidence of consultation between the ED Nurse
Co-ordinator and any medical staff to see if [Mr A] should be
brought through, despite a crowded department. This concurs with
past habits where GP referred inpatients are left for the referral
teams to see, even when busy or delayed elsewhere. This attitude
continues to prevail despite education and formal protocols."

(The Protocol referred to above outlines the responsibilities of
the triage nurse and the nurse coordinator in moving patients,
assessed as triage code 3, into assessment beds. The Protocol
states that patients assessed as triage codes 1 and 2 go into ED
immediately. Triage code 3 patients "go through to treatment spaces
if available - the remainder go to Reception and complete
Registration". The Protocol is dated November 2001 and was not
operating at the time of these events.)

Ms E advised me as follows:

"Prior to 2000hrs, [Dr J], ED MOSS
[Medical Officer Special Scale] read through the incoming patients'
notes and stated [Mr A] should be in the Department. I said I knew
[Mr A] was in the waiting room. I stated that [Mr A] was a priority
and that he would be the next person in. Two beds were being made
available (10-15 minutes maximum) and [Mr A] would have one of the
beds, the other was marked for a febrile child with abdominal pain.
There was also concern for another patient in the waiting room with
? DVT who arrived at 1710hrs at triage.

I do not recollect talking to the
medical admission team specifically about whether [Mr A] was
expected, but do remember commenting to one that beds were very
limited, and that there were priorities (meaning and including [Mr
A])."

Ms E said that although Mr A's triage code was not changed in
his notes it was verbally changed by the discussion between herself
and Dr J.

Ms E recalled that at approximately 8.00pm, she went to the
waiting room and apologised to those waiting to be seen by the
doctor. While she was there she took the opportunity to view all
the patients who were waiting. No one looked in distress or
uncomfortable and no relatives expressed concern. She asked anyone
who was concerned to contact either the triage nurse or reception.
Ms E stated that because beds were becoming available, and staff
knew what to do, she was satisfied that she could take a "brief"
break. After 8.00pm she had a 10 - 15 minute meal break. When she
returned she noted the following:

"The Department seemed to be busier,
with new arrivals; someone had a seizure and another person was
having chest pain. Also, one of the bed transfers to the ward had
not yet left the Department. It would have taken a few minutes to
catch up with the changes, and I realised [Mr A] had not yet been
brought into the Department.

At this time I was concerned there
was only one bed free in the corridor and I remember considering
this option and who could manage [Mr A], as well as dealing with
other Department business.

I went to the waiting room and
called for [Mr A] - somewhere between 2030hrs - 2045hrs. He was not
there. I checked elsewhere but he was not outside the department,
nor in the toilets."

Ms E said that she paged Ms F to inform her of the situation in
ED, which was causing her some concern, but her return call was
answered by one of the ED staff and she was not called to the
phone. Ms F therefore was not alerted to the situation.

At approximately 8.30pm Ms D reviewed Mr A and he told her that
he was "the same as on arrival" and the pain in his right leg
continued. Ms D did not take any formal observations. The Sentinel
Event Report notes that Mr A's triage category should have been
reviewed and raised at this time, according to the usual protocols
in ED.

The Sentinel Event Report records that a patient (named) who had
been treated in the ED, and had had previous discussions with Mr A,
returned to the waiting room at 8.55pm. She noticed that Mr A was
still there and looking "clammy and his attention and speech was
wandering".

At about 9.15pm Dr I, the radiologist who had diagnosed Mr A's
DVT earlier that day, came into ED. He found the waiting room
completely full. Dr I discussed Mr A, and a number of other
patients, with Dr J.

At 9.25pm Mr A returned to the reception desk. The receptionist
called Ms D. Ms D made the following observations about Mr A:

"Sweaty and pale yellowish to look
at. Asked if he had chest pain, and sent to the receptionist and
for a bed. [Mr A] stated he had no chest pain but felt SOB - short
of breath."

Ms D asked the receptionist to bring a bed but, as none were
available, she brought a wheelchair. Mr A was taken into ED and
placed on a bed. By this time Mr A was grey in colour and sweaty.
Ms D placed him on oxygen and handed him into the care of Ms E.

Ms E attached Mr A to a portable ECG monitor and, aided by a
house officer, moved him to the resuscitation bay. Mr A "arrested"
(his heart suddenly stopped beating), his eyes rolled and he had a
"seizure type episode". Mr A was roused when his name was called
and when Ms E shook his shoulder. She attached him to the central
monitoring system. A medical team, consisting of two medical
registrars and Dr J, was called. They commenced resuscitation, with
the assistance of ED nurses.

At 9.28pm one of the medical registrars recorded that Mr A was
"very, very distressed, sweaty, cyanosed" and his blood pressure
was 80/40. He continued Mr A's oxygen, commenced IV fluids and
administered Maxolon and morphine. He telephoned the consultant
cardiologist.

The consultant cardiologist recommended using a tissue-type
plasminogen activator (enzyme used to remove an arterial blockage)
and transferring Mr A to the Critical Care Unit (CCU). He informed
CCU and asked that they prepare for Mr A's arrival.

Ms E telephoned Mrs A to inform her about her husband and ask
her to come to the hospital urgently.

At 9.38pm Mr A suffered a second cardiac arrest as he was
leaving the resuscitation bay. Mr A was given direct current shock
treatment, 1mg of Adenosine, atropine and Gelofusin (a blood-fluid
substitute) while cardiopulmonary resuscitation (CPR) continued. At
9.51pm one of the medical registrars consulted the consultant
cardiologist. Mr A had no cardiac output and the medical registrar
considered it futile to continue with resuscitation. The consultant
cardiologist recommended that CPR be discontinued and Mr A died
soon after.

The medical registrar informed Mrs A of her husband's death. The
Police and Coroner were also informed. An autopsy report noted that
Mr A died from a "massive pulmonary embolism" with complicating DVT
in his right leg.

Ms E recalled:

"[A]s [Mrs A] left the Emergency
Department with her family, she asked for the overnight bag she had
brought in for her husband. I eventually located it in the
Department's children's waiting room. This concerned me because I
wondered if [Mr A] had been sitting there when I had called for him
previously at 2030-2045hrs. If so, he would not have heard his name
called and would not have been visible to anyone in the waiting
area or Department."

Subsequent events - concern about overcrowding in the
ED

At 9.30pm on 6 June an ED nurse filed an incident report. The
report stated:

"Inadequate staffing and beds to cope with the demand of
emergency presentations. Minimum three-hour wait - unfortunately
this man we couldn't get in to be seen - this resulted in him
moving from a DVT to a PE - doesn't look very good from a nursing
point of view."

Later that evening the ED nurse wrote to the General Manager of
the hospital, as follows:

"[V]ery unfortunate evening but this
is the fourth day in a row where we can't cope.

High patient activity

High patient demand

Lack of available beds

Lack of numbers both nurses and
Drs.

This is putting us in a very unsafe
condition and although the team have [been] worried out of [their]
skins and feel very unsafe no matter how fast/hard efficient we
work, more sick/sick [patients] are waiting. I wonder why three
nurses (senior) are leaving?"

Mr K, Chief Executive of the hospital, advised me that the
comments about senior staff leaving were "emotive" and that "staff
attrition is highly variable and seniority of staff fluctuates
depending on recruitment at any point of time".

Dr H advised me that the lack of beds in ED was first raised
with the Health Authority Secondary Services Report in 1994. The
report predicted that by 2001 the hospital would be "significantly
under bedded causing potential delay in patients accessing beds
acutely". In March 2001 she assisted with the preparation of a
report to the hospital in which she identified that the current bed
capacity in the district, according to international experts, fell
short by 100 (a 20% shortfall). (Mr K advised me that the number of
ED beds increased significantly in November 1999, when a new ED was
opened.)

Nursing staff wrote to the Chair of the District Health Board by
letter dated 7 June 2001. Staff stated that they wanted to
highlight the fact that they had expressed their concerns about
unsafe staffing levels in ED to Mr K, Chief Executive, at a meeting
with him in September 2000. Mr K informed them there was "a
temporary hiatus in patient presentations". The nursing staff, many
of whom were experienced ED nurses, did not share his view. There
had been no improvement and by mid-December the ED nurses and
doctors wrote to the General Manager outlining their continuing
concerns.

Mr K advised me that a number of meetings occurred between the
Nurse Manager ED and the General Manager between December 2000 and
February 2001 to develop strategies for managing nursing resource
and maintaining patient safety. The General Manager responded to
the staff letter on 31 January 2001 and outlined a number of
strategies that had been or would be implemented.

In the opinion of staff, it was not a constructive reply. The
staff letter had pointed out that many senior experienced nurses
were leaving and were usually replaced by less experienced nurses,
placing a greater burden on the remaining experienced staff.
Nursing staff had completed numerous incident forms, identifying
areas where staff shortages made nursing unsafe, but had received
little response and "no action". Nursing staff were frustrated by
what they perceived as the "inertia of management", and were fully
aware of the dangerous scenario in an overworked department.

The staff letter identified the "typical" events of the previous
evening with the patients triaged some 60 - 90 minutes after
arriving at the reception desk and staff being so busy that there
was no opportunity to retriage patients at the allotted times. As
an example of the dangers of the situation, the letter related the
events surrounding Mr A's case. Nurses were angry that management
seemed unwilling to intervene to stop an event that could happen
again if there was no change to the staffing levels. Nursing staff
requested legal advice about their culpability in such situations
and asked whether management shared some responsibility. They asked
that the Chair meet with the nursing staff and keep them fully
informed about any intervention the Board proposed to take.

Mr K advised me that it is not correct to say that management
was inert. Incident reports were investigated and reports generally
fed back to the appropriate department. He provided evidence that
non-clerical staffing numbers in ED increased significantly between
June 1999 and June 2002, from 27.58 to 39.09. At the time of these
events there were 35.45 staff rostered in ED even though only 34.9
staff were budgeted for.

On 7 June 2001 Dr I wrote to Dr H expressing his concern:

" ... ED staff were obviously under
considerable pressure during Wednesday evening, so much so that
patients with life-threatening problems were parked in the ED
hallway.

... a patient with a diagnosed
potentially life-threatening condition was not able to be commenced
on medical therapy sooner."

On 8 June 2001 at 8.00pm an ED staff nurse filled in an incident
notification sheet. The nurse stated:

"Unsafe working conditions -
[increased] patients [insufficient] beds available and [not]
complete ability to care for the demand at the emergency entrance.
Three-hour waiting time putting nurses at large risk."

Events contributing to overcrowding

Dr H advised me that problems arose during June 2001 for a
number of reasons:

"First, we had a sudden onslaught of
very ill elderly patients and those with significant multiple
disease presenting to the ED, just after Queen's birthday weekend.
This caught everyone by surprise resulting in a greater than 25%
increase in our daily ED attendances.

Second, as well as a rise in acute
attendances, we had a much greater number of significantly ill
patients requiring longer ED nursing and medical assessment and
care as well as requiring acute inpatient admission. Our bed
statistics at the time reflected this problem in that we were
admitting around 40 acutely ill patients per day and began each day
with 10 or more patients in hospital than we had beds available.
This meant that patients in hospital needed to be discharged before
those for admission could be brought up to the wards from the
ED.

Third, the ED had a total of 19
treatment beds (2 resuscitation, 1 procedure, 1 child, 5
observations and the others general treatment beds). The problems
we were having are that delays in accessing inpatient beds resulted
in the ED beds being blocked by these patients. Instead of Triage
category 2 and 3 patients accessing a medical review within the
prescribed time, patients were waiting for care - either on
trolleys in the hall or in the waiting room.

Fourth, for various reasons, a
number of our more senior experienced nursing staff had elected to
move on to other centres and we were left with a pool of less
experienced people and a real shortage of skills and numbers of
nursing staff.

Fifth, our junior medical pool was
in flux. Normally this happens as junior doctors who come to [the
town] primarily to enjoy the summer, decide to move on. This is
always a difficult time, as the British doctors are generally not
available until July/August and the ability to attract New Zealand
based doctors is limited due to demands in larger teaching centres.
Over the past four years, the ED has employed Junior doctors who
have a minimum of 3 post-graduate years training experience. These
people are difficult to come by but we have been much better placed
to provide better care with more experienced people. The good part
is that we have had a stable group of senior medical officers
overseeing the totality of care provided and this has enabled
improved team work in the ED."

Allocation of staff to triage roles and staff
training

In relation to nursing staff training and allocation of staff to
ED, Mrs G made the following statement:

"It has always been my practice as
Nurse Manager, to ensure that no nurse is assigned to the triage
role for a shift, without first having worked in the ED for at
least one year and successfully completed the Emergency Nurses'
College, formerly the Emergency Nurses' Section of NZNO, Triage
course or a similar certificated Triage Course, if the nurse has
trained overseas.

I do not assign nurses who have
trained and practised overseas, or in other New Zealand hospitals,
to the triage role until they have worked for at least six months
in the [hospital's] ED and have an understanding of the
demographics of the region, the types of illnesses and injuries
treated in the ED.

I also encourage discussion with
Co-ordination and triage staff regarding allocated triage codes and
am often asked to review these with a view to ongoing learning for
these staff.

...

Comment on Sentinel Event
Report

During the sentinel event
investigation into [Mr A's] case I repeatedly stated a request for
there to be a recommendation that there be a similar process of
investigation instituted for General Practitioners and other
primary care providers as I felt that positive changes may be able
to be made to pre hospital patient care. I continue to feel this
way as [Mrs A] particularly states in her letter to you, that she
believed 'the hospital appears to have downplayed the significance
of the communication between [Dr C] and the hospital staff'. As
mentioned earlier [Dr C] did not indicate in his letter to the
hospital that he was any more concerned about [Mr A] than he would
have been about a patient with a small lower leg DVT. It is my
opinion that [Ms D's] assessment of [Mr A] would have been
significantly changed had [Dr C] written extensive femoral
popliteal DVT.

... "

Mrs G further stated:

" ...

I have been actively involved in the teaching of triage
assessment skills in the [the hospital's] ED since September
1997.

I have actively sought placement for [the hospital's] ED staff
in triage training courses run by The College of Emergency Nurses,
on an annual basis.

I maintain a daily informal audit of the triage codes and
disposition of all patients who attend the ED.

I actively access patients' records to identify the basis for
triage code decisions and provide ongoing review with and education
of staff, should I identify any inconsistent decisions.

I identified the need for restriction on the staff who carried
out the Co-ordinator role in the ED to try and develop a more
consistent and supportive mentorship of less experienced staff and
to ensure that the patients brought into the Treatment area for
care were the most appropriate for the time.

Despite annual requests for a Clinical Nurse Educator in ED,
this has not been achieved.

I believe that there should also be a sentinel event inquiry
process established in the Primary Care Community in the event of
GP referred patients suffering an untoward outcome within 24 hours
of attending hospital."

With regard to allocation of staff to triage role and staff
training, Mrs G advised me:

"Comment on Triage
training

As mentioned earlier I have accessed
the triage training provided by the College of Emergency Nurses as
the sole formal education for ED staff. Of recent date I have had
some concern that the course may not be evolving to meet the
changes in management of illnesses in New Zealand. I believe that
the basic triage training available is appropriate, but I am of the
opinion that it could be extended beyond two days and that
scenarios of cases such as this, may be examined. I have expressed
these concerns to colleagues and recently spoke with [ ... ] the
Clinical Nurse Educator at [another public hospital's] ED regarding
this. [The Clinical Nurse Educator] has subsequently met with some
of the teaching staff of the triage course and has represented my
concerns, with which she agreed.

Allocation of Staff to
Triage Role

Allocation of staff to roles within
the ED is done on a daily basis by me as the Nurse Manager or in my
absence, by my assigned deputy. I do this to ensure that the triage
and co-ordinating 'teams' for each shift are the most compatible to
ensure ease of communication and understanding between them.

If there is a newly certificated
triage nurse assigned to triage this relationship is even more
important. I always ensure that the Co-ordinating Nurse is very
experienced and able to support the triageur by informally auditing
their assessments and coding. I also try to ensure that this staff
combination most often occurs on a morning shift when I am also
available to support and assess the performance of the triage
nurse.

On 06 June 2001 I was attending an
Emergency Care Co-ordination Team meeting in [a nearby town] and
had deliberately assigned [Ms E] and [Ms D] to Co-ordinating and
triage respectively for the afternoon shift. I had done this
because I was not in the Department and because the workload in the
Department over the preceding weeks had been very heavy. These two
staff worked well together and were in my opinion best suited to
manage the workload. Both staff had worked in ED for at least 10
years and were certificated in Trauma Nursing (TNCC), Advanced
Cardiac Life Support (ACLS) and Triage. [Ms D] also held a
Certificate in Emergency Nursing (CEN) qualification."

Review of Mr A's care - GP referral

Dr H advised me that, in her opinion, it is not ideal that
junior medical officers take GPs' referrals to the ED. In Mr A's
case it would have been better for a senior clinician to take the
call as a young medical officer did not have the experience to
decide what is the most appropriate action. The junior medical
officer does not discuss the matter with the medical team or a
senior clinician and the outcome was that Mr A was not seen by any
of the medical team in ED until it was too late.

Dr H raised concerns about the lack of clarity and direction in
ED procedures and systems. In her view, this "paralyses the
Emergency Department team's ability to work together". She noted
the difficulty that nursing staff experienced with conflicting
recommendations from senior nurses and medical staff. Dr H
requested that I recommend that "some clear protocols and
guidelines" be put in place for dealing with GP referrals to ED. Dr
H recommended that the practice in ED needed to be regularly
monitored and evaluated.

Dr C described the current system for GP referrals for acute
admission to the hospital, in a letter dated 12 January 2003:

"I was pleased to be invited to be
part of a series of [ ... ] District Health Board meetings referred
to as an Acute Care Forum in the later part of 2002, to help devise
a system that could prevent further such problems. [Mrs G] the ED
Nurse Manager, Mr [ ... ], recently appointed ED Clinical Director
and myself were charged to devise a new system of admission for
trial. Preliminary thoughts were conveyed back to the wider Forum
and subsequently refined for later meetings.

The final draft form of the system
... was referred to as the 'Single Portal of Entry' system of GP
admissions to [the hospital]. In particular, the issue of conveying
the GPs Level of Concern was highlighted, as was a faxed pro-forma
Admissions Letter which would clearly be the most important
Document to convey essential information to the Hospital ED
system.

The attached sheets were to be
printed double sided, laminated and distributed to all GPs and A
& M centres. A draft letter, written by myself, [was] proposed
to go out to all GPs ...

Much to my dismay, the final Acute
Care Forum meeting in October 2002 resulted in the plan being
shelved. The reasons for this appeared to revolve around the
internal politics of the Hospital as it related to Inpatients Teams
vs the Emergency Department, and concerns of the Junior staff, in
part as it related [to] their clinical training.

This has been most disappointing.
Efforts will be made this year to revive and further refine the
proposal if necessary to allow a trial to be mounted."

Recommendations following sentinel event
investigation

Following Mr A's death the sentinel event investigation
concluded that Mr A waited an unacceptably long time in ED before
he was seen by a doctor. A number of actions were identified to
help remedy the situation, including the following:

"This unfortunate man should not
have waited so long for assessment and treatment, however given the
severity of his condition, even with timely intervention he may not
have survived.

There are a number of process issues
to be addressed which contributed to the unacceptable delay this
man experienced in the ED and the untoward outcome.

I. Communications between
professional staff.

The sense of urgency for his
admission was not appreciated or perceived by the medical admitting
officer from the telephone discussion with the GP.

Action:

Review of referral process between
GPs and medical admitting teams to take place. Recommend that the
Consultant on call, or his Registrar should receive the incoming
calls from GPs. This would enable a higher level review of the need
for admission, and ability of the GP to manage the patient in the
community.

Action:

For expected admissions, a record of
expected admission to be logged on Emergency Department Admission
form by the receptionist, and kept as permanent record, rather than
'paper notelet', as at present, which is discarded when the patient
arrives.

Action:

Emergency Department Manager to
explore options of an information system in the waiting area,
advising patients of 'wait time to be seen' and encouraging
patients to present to reception if concerned.

II. Delay in initial and
subsequent Triage.

The current process is based on the
Australasian guidelines for Triage, and is appropriate for use in
the ED. On this occasion the established processes were not
followed rigorously.

Action:

If more than 8 attendances present
within one hour, ED Nurse Coordinator to be informed by the
receptionist and activate the ED Rapid Assessment Team, i.e. an
additional Triage Nurse and MOSS to be called forward to the
reception area. ED Nurse Coordinator also to inform Support Manager
of the hospital, alerting them of the increased level of activity
in the department. The external consult room, and interview rooms
should be used to assist with the processing of waiting patients.
[Mrs G advised me that this recommendation had been actioned in an
adjusted, more precise form and is now a part of the major incident
response escalation plan.]

Competency of nursing triage and
assessment. All nurses trained in Triage categorisation and
assessment skills.

Action:

Introduce use of the 'Wellington'
flow chart.

Competency reassessment of nursing
staff by audit of records and educator support.

ED Nurse Manager to review selection
criteria for 'triage nurses'.

Triage review:

[Mrs G advised me that at the time
of these events the last three criteria listed above had been in
place and operating for some time.]

Action:

Nurse Coordinator and Senior MOSS to
monitor triaged and waiting client files every 30 minutes, and
upscale triage category if outside the time limit. MOSS also to
re-prioritise clients for assessment. ED doctors are required to
see any patients, including those referred in for on call medical
teams, when admitting team delayed or busy.

III. Management of GP
referrals for medical assessment/admission.

Action:

Review of current process within ED
to be undertaken, led by the Clinical Directors of ED and Medicine.
Consider bypass of Nurse triage.

Additional 2 trolley spaces to be
created in ED when department busy and backlog of patients
developing.

Free standing screens required to
provide patient privacy when beds used in corridor areas. [Mrs G
advised me that fixed curtains, rather than free-standing screens,
have been installed.]

Trial to be implemented of Acute
Assessment space in the Interview room. [Mrs G said that this trial
had not proceeded and it does not now seem necessary.]

Trial of use of 'triage category'
for referrals from GPs and Ambulance officers. Senior Medical staff
to educate junior doctors in diagnostic probability analysis.

IV. Absence of Thrombolytic
therapy in ED.

Action:

Discuss with Cardiologists potential
to initiate thrombolysis in ED (as well as fast track clients to
CCU). Thrombolysis protocols and treatment regimes to be developed,
with education of ED staff in their use.

V. Procedures and clinical
protocols.

Action:

ED Clinical Director and Nurse
Manager to review existing protocols to ensure all requirements are
met.

VI. Nursing
Resources.

Action:

ED Nurse Manager has identified core
staff to take Triage and Coordinator roles to ensure consistency
and competency in performance. [Mrs G advised me that this has
always been her practice regarding triage allocation, and that she
introduced this prior to Mr A's attendance.]

Health Care Assistant role to be
trial led in support of nursing team to relieve Registered Nurses
of non nursing duties."

Implementation of Sentinel Event Report
recommendations

Dr H advised me that in response to these issues work has been
done to improve patient flows and in July 2001 three extra beds
were added to the Emergency Department. Even with this additional
capacity the ED continued to have problems when the number of
patients with acute illness or injury exceeded the number of beds
available. She predicted that problems would continue until more
beds are added.

On 19 July 2001 Mr K wrote to the Director-General of Health
advising her of the actions taken by the hospital to improve access
to health care in ED. His letter noted the following:

"The steps completed, or underway,
so far, are:

A Health Care Assistant has been employed to reduce some of the
non-clinical workload.

Discussions have been held with the General Medicine
Specialists to ensure they/or Registrars, are available to process
patients through the Emergency Department.

A parallel system for GP referrals for admission is being
investigated. A high proportion of referrals to the Emergency
Department at this time of the year are from GPs. Some of these
patients come with previously confirmed diagnosis but not all are
admitted into hospital (two-thirds admitted).

GPs will be reminded that they need to contact a Senior Medical
Staff Member when they refer to the Emergency Department.
Consideration is being given to establishing an 'emergency category
system' for GP use.

Two additional cubicle spaces are being created in the
Emergency Department to allow additional patients to be more
closely monitored whilst waiting.

The staff members at the meeting
indicated that they were satisfied that the issues were
progressively being addressed.

I must stress that in my opinion, many
of these solutions are not addressing the real problem in [the
district]. We have already seen additional costs being generated
which go well beyond our funding levels. I am sure your monitoring
unit have already reported their concern about the deficit we have
at [the hospital].

[The hospital] is now at the point where we cannot operate
within the funding level allocated, without increasing our clinical
risk. The average age of our patients and the ever increasing
volume, is creating an enormous strain on [our hospitals].
Although the problems in the Emergency Department are very real,
they reflect a hospital operating at a capacity level well above
its resourced levels."

Mrs G provided the following information in January 2002 about
the steps taken to improve access to ED services, which have
exacerbated staffing problems:

"Following the sentinel event investigation into this case, I
have purchased three more ED trolleys to enable more patients to be
given beds earlier, however this has exacerbated our staffing
situation. The three extra beds have resulted in an increase
of sick patients in the department but I have not been able to
secure funding for extra staff to care for them. In short the
problem and risk to patients has now been transferred from the
waiting room to the bed area of the department. This also has
resulted in increased workload for the staff in treatment areas and
reduces further their availability to assist the triage nurse if
required.

All the recommendations made in the sentinel event report that
were identified as my responsibility to action, are in place with
the exception of the information system in the waiting room
advising patients of 'wait time to be seen' and encouraging
patients to present to reception if concerned.

I have not introduced this facility because the waiting times
vary according to the triage codes assigned to patients, therefore
it would be misleading to have a standard time displayed.
Triage nurses have been strongly encouraged to ensure that patients
are aware they should voice any concerns they may have during their
waiting time.

Co-ordinator Role

A group of six senior staff who are well respected, have
extensive clinical knowledge and have displayed excellent
management skills have been appointed to Clinical Co-ordinator
roles since 06 June 2001. The need for this position was
identified by me earlier this year as I believed that Co-ordination
of the Department was in need of review as it was disjointed and
inconsistent. I was able to identify that Co-ordination was
being best achieved by a small group of very senior staff. I
also saw this role as crucial to achieving best allocation of
increasing patient numbers to nursing staff who were best able to
provide the care they required. It was also important for the
development and mentorship of less experienced staff as they would
have readier access to these senior staff. At the time of [Mr
A's] ED visit this was under trial with S/N [Ms E] one of two staff
undertaking the role.

Review of the appointment of Co-ordinators is now due and will
be undertaken using a questionnaire to all staff, late in February
2002.

…

Since my appointment to the Nurse Manager role, it [has] always
been my practice to informally audit the daily census printout for
each 24 hour period and note triage codes that have been allocated
for presenting problems. I also check the disposition for
each patient and review patient notes if the triage code and the
disposition do not correlate. Should I identify any
inconsistencies, I always speak with the nurse concerned and
provide advice and strategies to follow.

Since my appointment as Nurse Manager I have requested, on an
annual basis, that I be permitted to employ a Clinical Nurse
Educator for the ED. This request has not been successful to
date. The Staff Nurse FTE of the Department has increased
from 20.5 to 35.8 and I am no longer personally able to provide the
degree of departmental education required for this number of
staff.

Limiting the selection of triageurs to senior experienced staff
is, in theory, a very sound proposal but is difficult in practice
as there is always the need for newer staff to get clinical
experience in the role. My policy of matching the
Co-ordinators and the triage staff is I feel, the safest way to
achieve this."

Mrs G advised in February 2003 that the past practice of leaving
GP-referred inpatients for the referral teams to see, even when
busy or delayed elsewhere, no longer occurs. Patients are now
referred to the ED doctor for assessment, if the ED doctor is
available. There is now a closer working relationship between
the senior medical staff in ED and the nurse co-ordinator on each
shift.

Mr K advised me in January 2003 that as part of a campus
redevelopment an Acute Admissions Unit and expansion of the
Emergency Department is planned, and will improve the capacity of
the hospital to provide more rapid patient assessment and
treatment.

Independent advice to Commissioner

The following expert advice was obtained from Dr Mike Ardagh,
Professor in Emergency Medicine:

"Purpose

To advise the Commissioner on whether [the hospital's] Emergency
staff provided services with reasonable care and skill to [Mr
A].

Complaint

The complaint is outlined in [Mrs A's] letter to the
Commissioner but in essence her complaint is that:

[The hospital's] Emergency Department did not provide an
adequate standard of care to [Mr A] when he presented on 6 June
2001 at 5.20pm with a referral letter from his General
Practitioner, [Dr C], and a Doppler scan report from …
radiology. [Mr A] had a diagnosis of right deep vein
thrombosis and he was for admission. [Mr A] subsequently died
at 9.51pm while waiting to be seen by the medical team.

In particular, the Medical Admitting Officer, [Dr B], did
not:

Adequately ascertain [Mr A's] referral status during a
telephone referral discussion with [Dr C] on 6 June 2001 at 4.30pm.

Consult with senior medical staff regarding appropriate
management and/or communicate this to the appropriate staff in the
Emergency Department.

[Dr H's] response to the Commissioner, including Sentinel Event
investigation and other supporting documentation including Triage
and Observation Policies and letters outlining concerns about
pressures of work

[Mrs G's] response to the Commissioner

[Mr A's] medical records from [the hospital]

Expert Advice Required

To advise the Commissioner whether in my opinion, [Mr A] was
provided with services with reasonable care and skill while he was
at the Emergency Department at [the hospital] and in addition, to
answer the following questions.

What standards apply in this case and were those standards
met?

Whether the admitting house surgeon had the skill and
experience needed to adequately assess [Mr A's] referral status,
and if not, what level of medical practitioner should be given this
responsibility?

Whether the admitting house surgeon should have consulted
senior medical staff regarding the appropriate management and/or
communicate to the appropriate staff the information that he had
regarding [Mr A]?

Whether Triage Category 3 was appropriate, given [Mr A's]
medical history and diagnosis?

Whether formal observations should have been taken as a part of
the triage assessment and whether [Mr A's] triage category should
have been reviewed during the course of the evening?

Whether the Emergency Department Nurse Co-ordinator had a
responsibility to assess and review [Mr A's] triage category during
the course of the evening?

Whether it was appropriate for the Emergency Department Nurse
Co-ordinator to discuss [Mr A] with appropriate medical staff when
it was known he was in the waiting room for such a long time?

Whether the Emergency Department Nurse Co-ordinator should have
gained additional assistance when it was clear that the triage
guidelines were not met?

Whether the Director of Emergency Medicine should have ensured
that referral and consultation systems between General
Practitioners and Emergency Department Medical Admitting Teams were
appropriate?

Whether the Director of Emergency Medicine should have
responsibility to ensure that junior doctors were adequately
trained to take a patient referral status over the telephone?

Whether the Nurse Manager had a responsibility to ensure that
triage nursing staff were adequately trained to ascertain a
patient's triage status?

Summary of facts

I will very briefly reiterate key facts as I see them, but I
will not attempt to reproduce the sequence of events or the facts
in detail, as these have been well presented in the documentation
of the Sentinel Event Investigation. I will make some
comments regarding some of the events listed.

In summary these occurred:

[Mr A] was referred to the inpatient medical team by his
General Practitioner with a diagnosis of deep venous thrombosis
confirmed by ultrasound imaging.

Assessment of patients by inpatient medical teams referred in
this manner, is expected to occur in the Emergency Department.

[Mr A] presented to the Emergency Department where he waited an
hour and ten minutes for triage (or an hour and 15 minutes - there
is some variation in the triage time reported in the Sentinel Event
documentation). Ideally he should have been triaged within
ten minutes of presentation.

He was triaged as a triage category 3, meaning that he should
wait to be seen by a doctor no longer than 30 minutes. In my
opinion, this is an appropriate triage category for his
presentation, however it must be noted that the time to see a
doctor is the time from presentation, and therefore, by the time
[Mr A] had attained the triage category of 3, he was already 40
minutes beyond the time that he should have been seen by a
doctor.

Approximately four hours (again there is some variation in the
time he represented to triage and was taken through for medical
care) after presentation to [the hospital's] Emergency Department,
he was seen by a doctor. Medical assessment at this time was
precipitated by his marked deterioration.

Less than five hours after presentation to [the hospital's]
Emergency Department, [Mr A] had died consequent to a massive
pulmonary embolism.

Expert Advice Required

I will respond to each of the questions, asked of me by the
Commissioner, in turn.

What standards apply in this case and were these
standards met?

The Australasian triage scale is published on the website of the
Australasian College for Emergency Medicine and is accompanied by
documentation about its implementation in an Emergency Department.
According to the standards suggested in these documents, patients
should present to a triage nurse first, before an Emergency
Department receptionist, triage should be prompt (within 10 minutes
is a figure commonly employed) and patients should be seen by a
doctor within a certain time, according to their triage
categorisation. These standards were not met in this
case.

It must be noted however that triage is used as a means of
augmenting patient flow, according to clinical urgency, through a
system of patient care. The fact that these standards were not met
is not necessarily an indication that there was a problem with
triage, but instead that there was a problem with the system.
I will expand on this in discussion to follow.

In addition, the standards defining waiting times by triage
category include performance indicator thresholds which represent
the percentage of patients within a triage code, who commence
medical assessment and treatment within the relevant waiting time,
from the time of their arrival. In other words, the
expectation is that, when auditing performance, not all patients
will be seen within their triage code defined maximum waiting time,
as Emergency Departments are subject to considerable ebbs and flows
of demand which are not always predictable and seldom
controllable. The indicator threshold for triage code 3 is
that 75% of patients should be seen within the 30 minutes
defined. Although it may be argued that [Mr A] is one of the
25% allowed to fall outside this 30 minute period, it is my opinion
that a four hour wait to access medical attention in [Mr A's] case,
represents a failure of access to appropriate medical
attention.

Did the Admitting House Surgeon have the skill and
experience needed to adequately assess [Mr A's] referral status,
and if not, what level of medical practitioner should be given this
responsibility?

Contrary to some of the opinions presented in the documentation
received, my opinion is that the House Surgeon in this case did
have the skill and experience needed to adequately assess [Mr A's]
referral status. However I agree with many of the sentiments
expressed in the documentation that, in general, junior medical
officers should not be the ones taking General Practitioner
referrals, but instead such referrals should be taken by Registrars
or Consultants. The reasons for this have been discussed in
the documentation, but include the requirement for experience to
recognise the severity of illness, the urgency for medical care and
also intuitively, it is appropriate for a referral from an
experienced General Practitioner to be to someone who is not
considerably more junior. In this respect, it is pleasing to
see a change in practice for medical referrals at [the
hospital]. However, in [Mr A's] case, he was referred by his
General Practitioner as a patient with a deep venous
thrombosis. He had had some shortness of breath on exertion,
but in the referral letter this was associated with his recent
change in medication and there was no suggestion of a possible
pulmonary embolus. In addition, the subsequent report of the
General Practitioner suggests that he was thinking that the
shortness of breath may have been due to congestive heart
failure. Clearly [Mr A] had had pulmonary emboli already, in
the hours or days prior to presentation to [the hospital], but it
appears that in the eyes of the General Practitioner, the Medical
House Officer, and the Triage Nurse, he had presented with a large,
though uncomplicated, deep venous thrombosis. I think it is
likely that a more senior person on the end of the phone would not
have done anything differently to the house surgeon who took the
call.

Whether the Admitting House Surgeon should have
consulted senior medical staff regarding the appropriate management
and / or communicate to the appropriate staff the information that
he had regarding [Mr A]?

The comments in response to the previous question are relevant
to this one also. However, clearly communication is essential
when a patient is referred to one team but is received by
another. In this setting, it is extremely important that the
accepting team, who have taken information from the General
Practitioner, communicate this information to the receiving team
(the Emergency Department nurses and doctors) so that they are
aware of relevant information and the plan for patient
management. Otherwise the Emergency Department staff risk
leaving things out with an assumption others will do it, or
duplicating activities the admitting team intend to undertake.

Whether Triage Category 3 was appropriate given [Mr
A's] medical history and diagnosis?

Yes triage category 3 is appropriate.

Whether formal observation should have been taken as
part of the Triage Assessment and whether [Mr A's] triage category
should have been reviewed during the course of the
evening?

And

Whether the Emergency Department Nurse Co-ordinator had
a responsibility to assess and review [Mr A's] triage category
during the course of the evening?

It appears on the initial assessment, the Triage Nurse did take
some observations and these were normal. These are reproduced
in the Sentinel Event Investigation papers. As far as I can
tell, this initial assessment was an appropriate triage
assessment. Triage is a dynamic process and the triage
category should be changed as the patient's condition
changes. In addition, all patients in an Emergency
Department, both prior to and subsequent to seeing a doctor, should
have regular observations undertaken with a frequency determined by
their perceived seriousness or potential seriousness of
illness. [Mr A] was reassessed at 2030 hours, but no formal
recordings were taken. His formal recordings at this point
may well have remained normal, although another patient noted that
he was looking unwell at 2055 hours. Exactly when he began to
deteriorate is unclear, but it seems likely that it was between
2030 and 2055 hours.

The concept that a patient who has waited beyond their triage
category should be retriaged and given a higher category is, in my
view, wrong. Triage defines an urgency for care, which is
independent of other patients demanding services in the department
and how long the patient has been waiting. If [Mr A] was the
same at 2030 hours, as is alleged, then his triage category would
remain a triage category 3. A deterioration in his clinical
state does demand a review of the triage category because his
urgency has changed, but there is no indication to change his
triage category if his clinical condition has not changed.
Triage categorisation is a clinical observation, like temperature,
degree of pain, or degree of pallor. It is not altered by
factors independent of the patient (like ED workload) but it does
strongly influence where in the queue the patient waits.
However it is not the only determinant of where in the queue the
patient waits, and a waiting time already well beyond the accepted
threshold standards is a reason to advance up the queue, not
requiring a change in triage category. Indeed changing the
triage category for workload reasons manipulates a clinical
measure, alters department case mix measures and creates confusion
when dealing with an overloaded department and conflicting clinical
priorities. I strongly recommend 'up-triaging' is not used to
advance a patient up the queue.

Whether the Emergency Department Nurse Co-ordinator had
a responsibility to assess and review [Mr A's] triage category
during the course of the evening?

From the documentation received, it appears that the triage
nurse was a competent triage nurse. [Mr A's] triage category
3 was an appropriate one and there was no need for this to be
reviewed initially by the Nurse Co-ordinator, or by anyone
else. However, as [Mr A] waited beyond his triage category,
as discussed above, it is appropriate that he was reviewed to see
whether his clinical condition had changed. In addition, it
was appropriate that his medical assessment was expedited, with
increasing vigour, the further he went beyond the 30-minute
threshold.

Whether it was appropriate for the Emergency Department
Nurse Co-ordinator to discuss [Mr A] with appropriate medical
staff, when it was known he was in the waiting room for such a long
time?

Yes. A triage category 3 patient in the waiting room for a
number of hours represents a failure of access to care. It is
appropriate therefore for the staff in charge to do what they can,
to improve the access to care. The documentation received
suggests that such discussions did occur with the Medical Officer
of Special Scale on duty and there were some attempts to notify
others in the hospital, of the strains the Emergency Department was
under. It must be appreciated that the perception remained
that [Mr A] had an uncomplicated deep venous thrombosis and that
there were many other competing priorities at that time.

It seems clear from the documentation that all the staff in the
Emergency Department realised that what was happening to [Mr A] and
to other patients was a bad thing, but that they were somewhat
hamstrung in their abilities to do anything about it due to the
other and multiple demands placed upon them. This will be
discussed further.

Whether the Emergency Department Nurse Co-ordinator
should have gained additional assistance, when it was clear that
the triage guidelines were not met?

As discussed above, I understand attempts were made to gain
additional assistance, but that these attempts were either
incomplete (a return call was not received) or minimally effective
(only some patients could be moved). I, like many Emergency
Department practitioners around the country, am well aware of how
difficult it is to manage a situation of Emergency Department
overload of this type. Considerable and increased effort is
required internally to get through the overwhelming workload and at
the same time, attempts need to be made to lessen the external
influences contributing to the Emergency Department overload.
This will be discussed further.

Whether the Director of Emergency Medicine should have
ensured that referral and consultation systems between General
Practitioners and Emergency Department Medical Admitting teams were
appropriate?

This issue has been discussed by the Director of Emergency
Medicine and it is clear that attempts have been made to improve
the process of patient flow from the community to inpatient
admitting teams. The Emergency Department is an
integral part in such a system of patient flow, but it cannot claim
to control the system. It must be remembered that the Medical
Admitting Teams are not Emergency Department Medical Admitting
Teams, but are teams from other departments in the hospital, who
use the Emergency Department as a venue for assessing their acute
admission patients. In this respect, Emergency Medicine
Directors around the country have the frustrating problem of
incomplete influence over what happens in their departments.
It is my view that it is the responsibility of the General
Practitioners, the Emergency Department Director and the inpatient
admitting teams to ensure that referral and consultation systems
are appropriate, and not the responsibility of any one individual
or department.

Whether the Director of Emergency Medicine should have
responsibility to ensure that junior doctors were adequately
trained to take a patient referral status over the
telephone?

In reference to this case, the Director of Emergency Medicine
has limited influence over the activities of a house surgeon in a
medical team. This question is more relevant to the Director
of General Medicine.

Whether the Nurse Manager had a responsibility to
ensure that Triage Nursing staff were adequately trained to
ascertain a patient's triage status?

The Nurse Manager does have such a responsibility, but in this
case it appears the Nurse Manager had undertaken that
responsibility appropriately, despite difficulties in doing so
related to resources and access to education. I must
emphasise again that, in this case, the triage assessment and the
initial triage of category 3 were appropriate. The fact
that [Mr A] had to wait far longer than he should have for triage
and for medical care was inappropriate, but was not directly a
consequence of problems with triage. This will be discussed
further.

Conclusions and Discussion

[Mr A] died of a massive pulmonary embolus. He had a large
deep venous thrombosis and it is apparent that he had been having
small pulmonary emboli prior to presentation to [the hospital], and
he had a large pulmonary embolus while waiting for medical care in
the Emergency Department waiting room. It must be noted that
instigation of appropriate medical care for his deep venous
thrombosis 2-3 hours earlier may have made no difference to his
outcome. Indeed the medical team assessing him may well have
investigated him for pulmonary embolus and might not have started
any treatment prior to his large pulmonary embolus. However,
it remains a possibility that earlier medical assessment may have
been sufficient to save [Mr A's] life.

The only aspects of care below an acceptable standard that I can
identify are that he had to wait too long for triage by a triage
nurse and he had to wait too long for medical assessment. I
cannot find any fault with individual aspects of [Mr A's] care,
including the assessment and referral by the General Practitioner,
the acceptance of the referral by the Medical House Officer, the
triage of [Mr A] as triage category 3 and his attempted
resuscitation.

In regard to other criticisms of his care, it appears that he
was reassessed in the waiting room, although this reassessment may
have been cursory. It also appears that staff attempted to
get additional assistance to deal with the workload, although these
attempts were limited and largely unsuccessful. It also
appears that staff attempted to get [Mr A] into the department
earlier, but these attempts were limited by a lack of space in the
department and on one occasion, by being unable to locate [Mr A] in
the waiting room. These limitations, and the major
deficiencies related to waiting times are all a consequence of the
fact that the Emergency Department was overwhelmed.

Two important points need to be made here. The first is
that overwhelming, or overcrowding of Emergency Departments, is a
problem throughout New Zealand and I am unaware of any Emergency
Department in this country that manages to see their patients
consistently according to the standards defined by the triage
waiting times indicator thresholds. Secondly, the
overwhelming of the Emergency Department on the night that [Mr A]
presented was clearly not peculiar to that night and there is
correspondence in the documentation I received, attesting to the
frustrations, the low morale, and the concerns about patient safety
of the Emergency Department staff. The comments that follow
therefore are pertinent to [the hospital's] Emergency Department,
but indeed have national relevance.

Emergency Department overcrowding is a common phenomenon and has
a number of consequences which infringe the rights of patients in
terms of access to care and standards of care provided. When
departments are crowded, patients wait a long time for triage and
for medical assessment. The nursing resource is spread more
thinly and nursing observations and interventions occur less
frequently and less promptly than desired. Medical staff in
the Emergency Department are rushed and decisions, assessments and
medical interventions may be rushed or truncated as a
consequence. The contributors to Emergency Department
overcrowding can be considered in three categories.

The first category relates to the patient-load coming in the
door, and there are a number of interventions which can be utilised
to try and reduce the demand, such as the provision of robust
community After Hours Services, and patient education. The
second category relates to the Emergency Department resource
itself, and includes the physical space for patient care, as well
as the human resource for managing patients. The third
category relates to the ability to get patients out of the
department, particularly in to hospital beds. The difficulty
getting in to hospital beds may be related to the bed resource,
including nursing staff numbers, or may relate to systems which
involve the need for inpatient teams to complete a prolonged
work-up of the patient in the Emergency Department.

In [the hospital's] Emergency Department, as in many Emergency
Departments in this country, it is clear that the second and third
categories are significant contributors to overcrowding (the
contribution of the first category is unknown from the
documentation I received). It is clear therefore that
solutions to Emergency Department overcrowding, and the consequent
poor standards of care, are not purely the responsibility of
Emergency Departments, but require a consolidated response from the
Emergency Department, pre-hospital care and inpatient care.

Piecemeal attempts to solve the problem will have transient or
limited effect and the example of providing two extra Emergency
Department beds without an increased nursing resource to manage
those beds, is testament to this.

[The hospital's] Emergency Department has adequate expertise and
leadership, in the form of [Dr H] and the senior nursing staff, to
devise local solutions, but in general terms the following
initiatives are worthy of exploration:

1. Patient education and the
provision of robust acute After Hours General Practitioner
Services, to limit the requirement for Emergency Department
care.

2. A well resourced Emergency
Department with adequate space, nurses and doctors to undertaken
the specialist task of a modern Emergency Department.

3. Systems of patient flow which
maximise efficient use of space, and minimise duplication of
patient assessment. This would usually involve the Emergency
Department as the central conduit for all acute admissions, and the
Emergency Medicine staff as the doctors receiving the initial
referral and undertaking the initial assessment and stabilisation
then the definitive 'work-up' of the admitted patient would occur
in a setting outside the Emergency Department.

4. Systems and sufficient capacity
to allow the dispatch of patients from the Emergency Department to
inpatient beds without delay. This includes initiatives to
free up the existing inpatient bed resource, such as discharge
policies, discharge lounges, day of surgery admissions and early
access to rest home and nursing home beds.

Clearly these initiatives require a commitment to improving the
Emergency Department overcrowding problem by many who are not
directly troubled by it. To ensure [the hospital] resolves
the contributors to [Mr A's] poor care requires a leadership and
authority at least at the level of the DHB. To remedy this
problem nationally requires direction from the Ministry."

Code of Health and Disability Services Consumers' Rights

The following Right in the Code of Health and Disability
Services Consumers' Rights is applicable to this complaint:

RIGHT 4

Right to Services of an
Appropriate Standard

1) Every consumer has the right to
have services provided with reasonable care and skill.

Opinion: No breach

Mr A's wait for five hours at the hospital's ED before he
received medical attention was clearly unacceptable and may have
contributed to his tragic death. However, I am guided by my
advisor's advice that no individual aspects of Mr A's care,
including the assessment and referral by the general practitioner,
the acceptance of the referral by the medical house officer, the
triage of Mr A as triage code 3, and his attempted resuscitation,
can be faulted. While bearing in mind the significant issues
concerning the risks of an overcrowded and understaffed ED that
this case raises, I have accordingly formed the opinion that no one
individual breached the Code in this case. My reasons for
forming this opinion follow.

Dr B

In my opinion Dr B provided services with reasonable care and
skill and did not breach Right 4(1) of the Code.

Mrs A's complaint is that Dr B was too inexperienced to assess
Mr A's status from Dr C and should have consulted senior medical
staff about his condition and discussed appropriate
management. Furthermore, Dr B should have told ED medical
staff about Mr A's pending arrival.

Dr B was aware that Mr A was coming to ED with a DVT. He
did not consider Mr A an urgent referral because Dr C said that he
was stable and did not suggest that he had a pulmonary
embolism. In Dr B's mind, Mr A had an uncomplicated DVT and
was coming to ED for evaluation in the usual way. He telephoned ED
reception with Mr A's personal details and diagnosis. He did
not discuss Mr A with ED nursing or medical staff because it was
not the hospital's usual practice to do so unless the general
practitioner suggested that the patient could require urgent
medical attention.

Dr I had diagnosed Mr A's DVT by Doppler scan and reported his
findings to Dr C. Dr C discussed the scan results with Dr B
but had not seen the chest x-ray. Dr C explained Mr A's medical
history of hypertension, medication, his recent increase in
breathlessness on exertion, which could be congestive heart
failure, and his recent gout. I am satisfied that Dr C
conveyed the seriousness of Mr A's immediate clinical situation and
his need for urgent treatment.

My advisor agreed that, as a general rule, junior doctors lack
the skill to recognise the severity of an illness and the urgency
with which medical treatment is needed, and lack the intuitive
ability that comes with experience. My independent emergency
medicine specialist advised me that, contrary to Dr H's advice, Dr
B had the skill and experience to assess Mr A's referral. Dr
C was an experienced general practitioner who had examined Mr A and
considered that his breathlessness was due to heart failure,
whereas it is likely that he had had pulmonary emboli hours or even
days before.

My advisor indicated that despite his opinion that Dr B acted
reasonably, in this setting it is extremely important that the
accepting team, who have taken information from a general
practitioner, communicate this information to the receiving team
(the ED doctors and nurses) so that they are aware of the relevant
information and the plan for patient management.
Nevertheless, it is unlikely that a more senior person on the end
of the telephone would have done anything differently to Dr B when
he took the call from Mr A's general practitioner. I accept my
advisor's report.

In my opinion it was reasonable for Dr B to rely on the general
practitioner's advice and assume Mr A was being referred to ED with
an uncomplicated DVT. Accordingly, Dr B did not breach Right
4(1) of the Code.

Ms D

In my opinion Ms D provided services with reasonable care and
skill and did not breach Right 4(1) of the Code.

Mrs A's complaint is that Ms D did not adequately assess Mr A
because she did not take the results of his Doppler scan report or
Dr C's referral letter into account. As a consequence, Ms D's
allocation of triage code 3 was incorrect. Furthermore, Ms D
did not raise Mr A's triage category while he waited for medical
assessment.

Initial triage category allocation

The hospital informed me that a triage nurse would be expected
to look at all information, including radiology reports, as a part
of her triage assessment. The sentinel event investigation
indicated that Ms D did not seem to have taken into account Dr I's
radiology findings, which clearly identified the DVT, when she
completed her triage assessment.

Dr C's referral letter was brief and did not signal the need for
urgent medical treatment, since he had already conveyed the urgency
of the situation during his telephone call to Dr B. Ms D did
not read the radiology report because, due to the number of
arrivals in ED waiting for triage, she did not have time. Ms
D assessed Mr A at 6.30pm. Ms D took Mr A's observations,
which were within normal limits, and recorded that his colour was
good with no indication of shortness of breath. Ms D triaged
Mr A as code 3, which means that a doctor should have seen him
within 30 minutes of Ms D's assessment.

Ms D reviewed Mr A at 8.00pm. She documented that Mr A
told her his condition was unchanged and he still had the pain in
his leg. She did not take any formal observations or raise
his triage category. Ms D was expected to triage a maximum of
eight patients an hour, yet she needed to triage 14 patients
between 5.00pm and 6.00pm. Ms E confirmed that she took the
opportunity to quickly assess those waiting at 8.30pm and found no
one in distress or needing urgent medical attention.

My independent emergency medicine advisor noted that
reallocation of triage categories for patients who have waited
beyond their triage time is, in his view, wrong. Triage
allocation is a dynamic process, which should be changed as a
patient's condition changes. Patients' observations should be
taken regularly and the frequency with which observations are taken
must be in keeping with the severity of the illness or potential
seriousness of the diagnosis. He concluded that if Ms D had
taken Mr A's observations at 8.30pm, in all probability they would
have been unchanged. Mr A was noted to be unwell about half
an hour later.

Triage is a measure of urgency that is independent of other
patients demanding services or how long a patient has waited.
Triage categorisation is a clinical observation like any other, and
is not altered by factors external to the patient. As Mr A
was triage category 3 at 6.30pm and his condition was unchanged at
8.30pm, his demand for medical attention was unchanged.

It cannot be established when Mr A developed the pulmonary
embolism. Clearly Mr A needed to be seen by a doctor as he
had waited several hours in ED with a potentially serious medical
condition. However, his medical condition, when Ms D saw him
at 8.30pm, gave her no reason to alter his triage category or seek
immediate medical attention. For these reasons, in my opinion
Ms D acted appropriately and did not breach Right 4(1) of the
Code.

Ms E

In my opinion Ms E provided services with reasonable care and
skill and did not breach Right 4(1) of the Code.

Mrs A's complaint is that Ms E did not adequately assess Mr A
because she did not review the results of his Doppler scan report
or Dr C's referral letter. As a consequence, Ms D's
allocation of triage status 3, with which she agreed, was
incorrect. Furthermore, Ms E did not raise Mr A's triage
category while he waited for medical assessment and did not seek
additional assistance from the operations manager, Ms F, when it
became obvious that triage times had not been met.

Triage category - initial assessment

I have addressed the issue of alteration of triage category
above. However, the circumstances of this case, as noted by my
independent advisor, suggest that the issue is not one of triage
category. My independent specialist in emergency medicine advised
me that when Mr A was not seen by a doctor within 30 minutes
(triage 3 time frame), his case should have been discussed with the
emergency doctor because he was being denied access to medical
care.

Ms E and the emergency doctor, Dr J, discussed Mr A at about 8pm
and they agreed that he needed to be seen by a doctor as soon as
possible. There was no bed immediately available but two beds
were becoming free at about 8.30pm. Ms E went into the
waiting room to notify Mr A but she could not find him. If he had
been in the children's waiting area, he would not have heard her or
been seen by her.

Additional assistance

As the nurse co-ordinator in ED, it was Ms E's role to find beds
for patients in ED. She did this by assisting the flow of
patients through ED, either for transfer to the ward or discharge
home. She was in constant communication with the operations
manager, Ms F, as well as with other departments within the
hospital, and with patients and their families in the waiting
room.

Ms F recalled that, to her knowledge, the longest wait between a
request for a bed and availability was 20 minutes and she was not
informed that triage times were not being met.

Ms E does not recall whether she informed Ms F about the backlog
of patients waiting for a bed or that triage times were not being
met because this situation was not unusual. She had to make
beds available for sick children and for patients coming to the
hospital by ambulance. This meant that fewer beds were
available for adult patients. Earlier in the shift she
obtained additional nursing assistance, although this was limited,
and did not solve the problems incurred by overwhelming patient
numbers and the backlog of patients waiting for a bed. Ms E
attempted, unsuccessfully, to contact Ms F to inform her of the
situation when she returned to ED sometime after 8.00pm.

There is evidence that the chronic shortage of beds in the ED
had been discussed at senior management level. On the night
of 6 June, Ms E did not specifically tell Ms F she needed a bed for
Mr A because it was not unusual for patients to wait beyond their
triage times; in fact it was so usual as to be considered normal
practice. There were competing priorities for beds in ED at a
time when Mr A's condition remained unchanged.

I accept my advisor's conclusion that Mr A was perceived to have
an uncomplicated DVT and that Ms E was powerless to cope with the
overwhelming patient demand operating at the time. In my
opinion, in these circumstances Ms E responded appropriately and
did not breach Right 4(1) of the Code.

Mrs G

In my opinion Mrs G provided services with reasonable care and
skill and did not breach Right 4(1) of the Code.

The complaint against Mrs G is that she failed to ensure that
triage nurses were adequately trained.

As Nurse Manager, Mrs G had a responsibility to ensure that the
nurses she was supervising were appropriately trained in triage
assessment. Mrs G used the College of Emergency Nurses
education programme for formal education of basic triage training
of ED staff. However, she had some concerns about whether the
College's programme was able to keep up to date with changing
demands in patient management. In her opinion triage training
could not be covered in the two-day programme. She approached
colleagues and the nurse educator at another public hospital, who
undertook to raise the issue with the College.

I am satisfied that Mrs G carried out her responsibilities
appropriately and did not breach Right 4(1) of the Code.

Dr H

The complaint against Dr H is that she failed to ensure that the
referral system between general practitioners and the ED medical
team was appropriate, and that the junior admitting doctor was
adequately trained to ascertain a patient's referral
status.

Referral system between GPs and the ED

The evidence indicates that Dr H was not responsible for
ensuring that the referral system between general practitioners and
the hospital's Emergency Department functioned effectively.
The practice was that general practitioners referring patients to
the hospital would contact the admitting house surgeon, who would
use the ED to review the patient and decide whether to admit to the
ward or discharge. The admitting house surgeon was answerable
to the medical consultant. In Dr H's opinion, with which I
concur, this made the line of accountability uncertain.

Training of junior medical admitting doctors

As Clinical Director of Emergency Services at the hospital, Dr
H's role was limited to managing patients who either self-referred
or were brought to ED by ambulance. General practitioners
wishing to admit acute patients spoke directly to the admitting
house surgeon, a member of the inpatient medical team. My
independent emergency medicine specialist noted that inpatient
medical admitting teams are not emergency department medical
admitting teams, but are teams from other departments in the
hospital that use ED as a venue to assess their acute patients for
admission.

Dr B was a member of the inpatient medical team. As admitting
doctor for the medical team, he reported to the Clinical Director
of General Medicine, not the Director of Emergency Services.
Accordingly, it was not Dr H's responsibility to ensure that Dr B
was adequately trained to assess a patient's referral status. Dr H
considered that it was not appropriate for very junior doctors to
take telephone referrals without supervision, and would have
preferred all referrals to go directly to the senior ED doctor;
however, the matter was beyond her control. It is, however,
clear that Dr H raised this issue and made attempts to improve the
process for admission of patients.

In my opinion Dr H responded appropriately in a difficult
situation as Clinical Director of Emergency Services, and did not
breach Right 4(1) of the Code.

Opinion: Breach

The public hospital

My independent emergency medicine specialist advised me that the
only aspect of Mr A's care that fell below an acceptable standard
was that he had to wait too long for triage assessment and too long
for medical attention. This occurred because ED did not have
the capacity to cope with the number of patients attending, which
impacted on Mr A's ability to access hospital services, and on the
standard of care he received.

Overcrowding in ED occurs in many hospitals in New
Zealand. The evidence suggests that overcrowding at the
public hospital was not unusual. It was so "usual" that staff
had raised the issue with hospital management some time before, and
the Chief Executive Officer had conveyed the hospital's concerns to
the Director-General of Health.

I note the following points:

The lack of beds in the ED was first raised with the Regional
Health Authority Secondary Services Report in 1994. The
report predicted that by 2001 the hospital would be "significantly
under bedded causing potential delay in patients accessing beds
acutely". Mr K advised me that a new ED opened in November
1999 with significant increase in ED bed numbers and staff.

In September 2000 the hospital's Emergency Nurses had a
discussion with the Chief Executive Officer regarding their serious
concerns about safe staffing levels in the ED.

In mid-December 2000 things had not improved, and a letter was
signed by many ED nurses and doctors and sent to the General
Manager of the hospital, outlining their concerns. The
management response in late January 2001 was considered inadequate
by staff.

In March 2001 Dr H assisted in a report to the hospital in
which she identified that the current bed capacity in the district
fell short by 100 (according to international standards).

In a letter dated 7 June 2001 to the Chair of the District
Health Board, ED nurses indicated that numerous incident forms had
been sent to management identifying areas of unsafe staffing levels
and noted that there had been little response and no support from
management.

Mr K provided evidence that ED non-clerical staffing numbers
increased significantly between June 1999 and 2002, sometimes in
excess of the budget. Between December 2000 and February 2001
the Nurse Manager in ED and the General Manager met on a number of
occasions to develop strategies for managing the nursing resource
and maintaining patient safety.

The Chief Executive Officer relayed the nurses' concerns to the
Director-General of Health. In a follow-up letter, dated 19
July 2001, the Chief Executive Officer noted that "the issues were
further exacerbated by two unfortunate deaths", and sought
additional funding.

It is clear that the issue of understaffing and overcrowding of
the hospital's ED, and the associated risks for patient safety,
were brought to the attention of the District Health Board as early
as 1994, and more recently from September 2000. Despite the
hospital's response to the concerns, it is highly unsatisfactory
that the issues remained unresolved. The tragic potential
consequences of understaffing and overcrowding are evident in this
case.

My advisor noted that, in general terms, the causes of
overcrowding in EDs fall into three categories: the number of
patients attending ED at any one time; the adequacy of ED in terms
of physical space and staff available to cope with the numbers; and
the ability to move patients out of ED into hospital or the
community. It appears that issues related to the second and
third categories significantly impacted on the care Mr A
received.

In my opinion Mr A did not receive an appropriate standard of
care at the hospital's ED on 6 June 2001. If a solution to
these problems is to be found there must be a combined effort
between the community, Emergency Department management and
inpatient services. There is sufficient local expertise to
devise an appropriate solution.

Although I am satisfied that individual staff members provided
reasonable care, the hospital must accept responsibility for the
system that failed Mr A. Accordingly, in my opinion the
hospital breached Right 4(1) of the Code.

Recommended actions

I commend the hospital on the steps it has taken to limit ED
overcrowding. However, my advisor indicated that ad hoc
solutions will have a limited effect. I recommend that the
hospital take the following actions:

Bring together its senior management, medical and nursing
personnel to address the issues raised by my advisor to limit ED
congestion: community after-hours services and patient education;
physical space and personnel to manage patient load; and the
ability to exit patients from the ED (currently exacerbated by the
need for inpatient teams to complete a prolonged work-up of
patients in ED).

Work with local general practitioners to implement an effective
system for a single portal of entry system for GP referrals for
acute admissions to the hospital.

Ensure that clear protocols and guidelines are in place to deal
with GP referrals for acute admissions to the hospital.

Further actions

A copy of this report will be sent to the Medical Council, the
Nursing Council, the Director-General of Health and the Minister of
Health. I will request that the Director-General of Health
arrange for the Ministry of Health to audit the public hospital and
advise me by 30 June 2003 of the steps taken to implement my
recommendations.

A copy of this opinion, with personal identifying details
removed, will be sent to the Australasian College of Emergency
Medicine (New Zealand Faculty); the Royal Australasian College of
Physicians; the Deputy Director-General, Clinical Services;
Ministry of Health (for distribution to all District Health
Boards); and Quality Health New Zealand, and placed on the Health
and Disability Commissioner website, www.hdc.org.nz, for educational purposes.